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2008 Health Insurance Questionnaire

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2008 Health Insurance Questionnaire Powered By Docstoc
					                                    2008 Health Insurance Survey

INTRO1.      Hello. My name is __________ and I'm calling on behalf of the Commonwealth of
Massachusetts. I‟m with International Communications Research.

(INTERVIEWER SHOULD CONFIRM THAT RESPONDENT IS 18 OR OLDER. OTHERWISE ASK
TO SPEAK WITH SOMEONE IN THE HOUSEHOLD WHO IS 18 OR OLDER)

IF RDD or listed telephone from USPS sample: We are working on a study about health care in
Massachusetts. As a thank you for your contribution to this important research, we will enter eligible
households in a drawing for a $100 gift certificate or 2 Red Sox tickets.

IF other USPS sample: We are working on a study about health care in Massachusetts. As a thank you
for your contribution to this important research, we will send eligible households $20 and also enter you
in a drawing for a $100 prize or 2 Red Sox tickets.


INTRO2.       As you may know, Massachusetts is one of several states taking the lead in finding ways to
make health care more affordable and easier to obtain. The state would like to better understand how to
improve access to affordable health insurance.

INTERVIEWER: IF YOU REACH A CHILD, ASK TO SPEAK TO AN ADULT.

FOR RDD sample: Your telephone number was randomly selected from phone numbers in
Massachusetts. Your participation in this study is voluntary and will be a great help. This study takes
only about 25 minutes. (IF NEEDED: It tends to be a bit shorter for smaller households and a bit longer
for larger households.) (IF NEEDED, READ: As I mentioned, we‟re offering a chance to win a pair of
Red Sox tickets or a $100 gift certificate to each eligible household that completes the survey as a thank
you.)

FOR USPS sample with listed landline phone: Your address was randomly selected from residential
addresses in Massachusetts. Your participation in this study is voluntary and will be a great help. This
study takes only about 25 minutes. (IF NEEDED: It tends to be a bit shorter for smaller households and a
bit longer for larger households.) (IF NEEDED, READ: As I mentioned, we‟re offering a chance to win
a pair of Red Sox tickets or a $100 gift certificate to each eligible household that completes the survey as
a thank you.)

FOR remaining USPS sample: Your address was randomly selected from residential addresses in
Massachusetts. Your participation in this study is voluntary and will be a great help. This study takes
only about 25 minutes. (IF NEEDED: It tends to be a bit shorter for smaller households and a bit longer
for larger households.) (IF NEEDED, READ: As I mentioned, we‟re offering a $20 payment to each
eligible household that completes the survey as a thank you. We‟re also offering a chance to win a pair
of Red Sox tickets or a $100 gift certificate.)
INTRO3.       Before we start, let me tell you that everything you say will be kept private. Your answers
will be combined with those of other people in Massachusetts. The study will not be used for marketing
purposes and your decision whether or not to participate will not have any effect on anything to do with
your insurance coverage, health care, or your relationship with any state agencies in Massachusetts. You
may skip over questions or stop the interview at any time you wish.

IF RESPONDENT RAISES CONCERNS ABOUT THE INDIVIDUAL MANDATE: Since all of
the information that you provide will be kept private, there is no way that anything you say could be used
to determine whether you are complying with the individual mandate on insurance coverage.

INTRO4.        If you have questions about the study, I can give you a phone number now or at the end of
the survey that you can call to find out more about the study.

   For questions about the survey, please call Susan Sherr 1-800-633-1986.

   To speak with someone from the agency responsible for this survey, please call Cindy Wacks at 617-
   988-3174.

   S1.   First of all, is this a second home or vacation home?

         1    Yes
         2    No
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

   S5.   Is this a house, condominium, apartment, mobile home, some other kind of private residence, or
          something else? (DO NOT READ)

         1    House or row house
         2    Condominium or apartment
         3    Mobile home or trailer
         4    Other private residence
         10   Other Non-private residence (such as a group home)
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

   (IF S5 = 10, D, R READ: THANK YOU. WE ARE ONLY INTERVIEWING PEOPLE
   IN THEIR PRIVATE RESIDENCE.)




                                                   -2-
(ASK S1B IF IF S1=1 AND RDD SAMPLE or USPS SAMPLE WITH LISTED LANDLINE PHONE
IF REMAINING USPS SAMPLE, READ: Thank you. We are only interviewing people at their main
residence. TERMINATE
ASK S1b IF Q.S1=1)

  S1b. Is the telephone number I dialed, xxx-xxx-xxxx, the number I would use to reach you at
 your main residence?

         1   Yes                                         CONTINUE
         2   No                                          (READ: Thank you. We are only
                                                         interviewing people at their main residence.
                                                         TERMINATE)
         D   (DO NOT READ) Don‟t know                    (READ: Thank you. We are only
                                                         interviewing people at their main residence.
                                                         TERMINATE)
         R   (DO NOT READ) Refused                       (READ: Thank you. We are only
                                                         interviewing people at their main residence.
                                                         TERMINATE)


  (IF Q.S1 = D OR R OR Q.S1b=2, D OR R TERMINATE AND RECORD AS TQS1. IF Q.S1 = 2
OR Q.S1b=1, CONTINUE)

  (INTERVIEWER READ) I‟d like to begin by asking some questions about health
  insurance coverage for people in your household.

  S2.    Can you answer questions about health insurance for people in this household?

         1   Yes
         2   No
         D   (DO NOT READ) Don‟t know
         R   (DO NOT READ) Refused

  (IF S2=2, D, R; ASK S3)
  S3. Is another adult available who could answer questions about health insurance?

         1   Yes                                         GET PERSON ON PHONE AND
                                                         CONTINUE [SKIP TO INTRO1]
         2   No                                          SET UP CALL BACK.
         D   (DO NOT READ) Don‟t know                    (THANK AND TERMINATE)
         R   (DO NOT READ) Refused                       (THANK AND TERMINATE)

   S4.   How many people currently live or stay here? Please include anyone temporarily away for
          school or the armed services.
         (PROBE: Include in this number, children, foster children, roomers, or housemates not related
          to you, college students living away while attending college and National Guard members who
          are deployed.)
         (Do not include people who live or stay at another place most of the time, people in a
          correctional facility, nursing home, or residential facility, or people in the regular Armed
          Forces living somewhere else.)

         ________ people (RANGE 1-10)
         D (DO NOT READ) Don‟t know                      (THANK AND TERMINATE)
         R (DO NOT READ) Refused                         (THANK AND TERMINATE)
                                                 -3-
(INTERVIEWER READ IF Q.S4 = 2+) I need some general information about the
people in this house so that one person can be picked at random to talk about their access to
health insurance.

ASK S6 TO S9 IN SUCCESSION FOR EACH MEMBER OF THE HOUSEHOLD
(PN: Questions S6 – S9 can be used to create a “HH Roster” listing each person in HH)
S6. Starting with yourself, what is your age?
      (INTERVIEWER IF RESPONDENT DK/REFUSES AGE: I understand your
      reluctance to give your age, but this information is totally confidential. It is very
      important that we gather this information accurately to help improve health insurance
      coverage for Massachusetts‟ families. IF RESPONDENT STILL DK/REFUSES
      AGE, ASK Q.S6a1)

      ___________ (AGE)
          RR (DO NOT READ) Refused

(ASK Q.S6a1 IF Q.S6 = DD OR RR)
S6a1. Could you please tell me if you are…?
      (READ LIST. ENTER ONE ONLY)

      1    Less than 18 years of age
      2    18 years of age or older
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(IF S6<18 OR Q.S6a1 = 1, D, OR R; ASK S6A)
S6A. Is there someone available who is 18 or older?

      1    Yes                                        GET PERSON ON PHONE AND
                                                      CONTINUE [SKIP TO INTRO1]
      2    No                                         SET UP CALL BACK
      D    (DO NOT READ) Don‟t know                   (THANK AND TERMINATE)
      R    (DO NOT READ) Refused                      (THANK AND TERMINATE)

S6aa. RECORD RESPONDENT GENDER

      1    Male
      2    Female

S6(b-j). And the next person‟s age?
      (INTERVIEWER IF RESPONDENT DK/REFUSES AGE: I understand your
      reluctance to give other household members‟ ages, but this information is totally
      confidential. It is very important that we gather this information accurately to help
      improve health insurance coverage for Massachusetts‟ families. IF RESPONDENT
      STILL DK/REFUSES AGE, ASK Q.S6b1)

      __________ years (ENTER AGE 1-110)
      00 Less than 1 year old
      DD (DO NOT READ) Don‟t know
      RR (DO NOT READ) Refused




                                                -4-
(ASK Q.S6b1 FOR EACH Q.S6b-j = DD OR RR)
  S6b1. Could you please tell me if this person is…?
        (READ LIST. ENTER ONE ONLY)

         1    Less than 18 years of age
         2    18 years of age or older
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

   IF Q.S6(b-j) = 18+ OR Q.S6b1 = 2, INSERT “person” and “male or female”
   IF Q.S6(b-j) IS <18 OR Q.S6b1 = 1, INSERT “child” and boy or girl”
   S7(b-j). Is this (child/person) (a boy or a girl/male or female)?

         1    Male/Boy
         2    Female/Girl
         R    (DO NOT READ) Refused

   S8(b-j). What is this person‟s relationship to you?
         (DO NOT READ. ENTER ONE ONLY. R CAN PROVIDE UP TO ONE
         PARTNER AND FOUR PARENTS, GUARDIAN AND WARD SHOULD BE
         CODED BEFORE ANY OTHER RELATIONSHIP EXCEPT PARENT OR
         STEPPARENT OR CHILD/STEPCHILD/FOSTER CHILD, SO A
         GRANDPARENT AND GUARDIAN SHOULD BE CODED AS GUARDIAN)

         (INTERVIEWER IF RESPONDENT REFUSES RELATIONSHIP: I understand your
         reluctance to give your relationship to other members of your household, but this information is
         totally confidential. It is very important that we gather this information accurately to help
         improve health insurance coverage for Massachusetts‟ families. IF

         RESPONDENT STILL REFUSES RELATIONSHIP, THANK AND TERMINATE.)

         01   Spouse (wife/husband)
         02   Unmarried partner / significant other
         03   Child / stepchild / foster child/ward
         04   Parent / Stepparent / foster parent/guardian
         05   Sibling / Stepsister / Stepbrother
         06   Grandparent / Step-grandparent
         07   Grandchild / Step-grandchild
         08   Son-in-law / Daughter-in-law
         09   Father-in-law / Mother-in-law
         10   Other relative
         11   Employer
         12   Employee (maid, nanny, au pair, housekeeper, etc.)
         13   Professional caregiver (nurse, aide, etc.)
         14   Other non-relative
         DD   (DO NOT READ) Don‟t know
         RR   (DO NOT READ) Refused




                                                   -5-
   ASK IF S6 >/= 16
   S9   What is the highest level of school [you have/she has/he has] completed or the highest degree
        [you have/she has/he has] received?

         (DO NOT READ. ENTER ONE ONLY)

         1    Less than high school (grades 1-11, grade 12 but no diploma)
         2    High school graduate or equivalent (e.g. GED)
         3    Some college but no degree (incl. 2 year occupational or vocational programs)
         4    Associates Degree (not occupation or vocational programs)
         5    College graduate (e.g. BA, AB, BS)
         6    Postgraduate (e.g. MA, MS, MEng, Med, MSW, MBA, MD, DDs, PhD, JD, LLB, DVM)
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

(IF Q.S7=1 INSERT “he”; IF Q.S7=2, INSERT “she”, ELSE INSERT “they”)
(IF S6(a-j) = >16 ASK)
S9a       [Are you /Is she /Is he] currently working for pay?

         1    Yes, working
         2    No, not working
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused


FOR RESPONDENT, INSERT “you”
  (IF Q.S4 = 1, READ VERBIAGE IN PARENS)
  S10. I will be asking some specific insurance coverage questions about one randomly chosen person
        from your household. For those questions my computer has selected [you/TARGET].
         (I will be asking some specific questions about your insurance coverage)

         INTERVIEWER RECORD

         1    Respondent
         2    Target

   (P.N. – IF RANDOM PERSON CHOSEN IS TARGET AND Q.S6b1 = D OR R FOR
    THAT PERSON OR Q.S8b-j = RR FOR THAT PERSON, THANK AND TERMINATE)

   S10a. What is the first name or initials of the person I selected?

         1    Answer given (SPECIFY) ______________
         R    Refused




                                                    -6-
  IF AGE >=17, ASK Q.S11 AND IDENTIFY SPOUSE/PARTNER (S11=1 OR 2) IN
  THE ROSTER (TSPOUSE)
  INSERT “is this person” IF Q.S10 = 2
  IF TARGET IS RESPONDENT‟S SPOUSE, GEN IN CODE 1
  S11. Are you (is this person) currently:

        1    Married
        2    Living with partner
        3    Divorced
        4    Separated
        5    Widowed
        6    Never Married
        D    (DO NOT READ) Don‟t know
        R    (DO NOT READ) Refused

IF TARGET IS THE RESPONDENT, SKIP TO SETUP 1

  (ASK Q.S12 OF EVERYONE EXCEPT FOR RESPONDENT)
  S12(b-j). It would be helpful to know the relationship between the other members of your
            household and (INSERT NAME OR INITIALS FROM Q.S10a OR
            RELATIONSHIP FROM Q.S8[b-j])? What is the
            relationship of your (RELATIONSHIP FROM Q.S8[b-j] [INSERT
            AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j] if multiple members with same
            relationship code] to the TARGET)?
            (DO NOT READ, ENTER ONE ONLY, GUARDIAN AND WARD SHOULD
            BE CODED BEFORE ANY OTHER RELATIONSHIP EXCEPT PARENT OR
            STEPPARENT OR CHILD/STEPCHILD/FOSTER CHILD, SO A
            GRANDPARENT AND GUARDIAN SHOULD BE CODED AS GUARDIAN))

        01   Spouse (wife/husband)
        02   Unmarried partner / significant other
        03   Child / stepchild / foster child/ward
        04   Parent / Stepparent / foster parent/guardian
        05   Sibling / Stepsister / Stepbrother
        06   Grandparent / Step-grandparent
        07   Grandchild / Step-grandchild
        08   Son-in-law / Daughter-in-law
        09   Father-in-law / Mother-in-law
        10   Other relative
        11   Employer
        12   Employee (maid, nanny, au pair, housekeeper, etc.)
        13   Professional caregiver (nurse, aide, etc)
        14   Other non-relative
        DD   (DO NOT READ) Don‟t know
        RR   (DO NOT READ) Refused




                                                -7-
SETUP1:

P.N. - Create the following variables to be used in remainder of survey

HH_COUNT – Number of people in household (S4)
TMARR – 1 if TARGET is married/partner; 0 otherwise
TPAR – 1 if TARGET is parent; 0 otherwise
TAGE – TARGET’s age
TFEM – 1 if TARGET is female; 0 otherwise
TFAM_COUNT – Number of people in TARGET’s family.
  IF TAGE<19 & TMARR=0 & TPAR=0: TARGET+PARENTS+SIBLINGS<19 FROM
   ROSTER
  IF TAGE<19 & (TMARR=1 OR TPAR=1): TARGET+SPOUSE+CHILDREN<19 FROM
   ROSTER
  IF TAGE>18: TARGET+SPOUSE+CHILDREN<19 FROM ROSTER




                                                -8-
HEALTH INSURANCE

   INSERT “you/have/do you” IF Q.S10 = 1
   INSERT “NAME/INITIALS/RELATIONSHIP/has/does…” IF Q.S10 = 2
   (ASK ITEMS b, i, j, and l if TAGE>17)
   (ASK ITEM c IF H1b < 1 >)
   (ASK ITEM l IF H1b AND H1c < 1 >)
   (ASK ITEM M IF H1l AND H1b AND H1c < 1 >)
   (ASK ITEM k if TAGE>15 AND </=64 AND H1b AND H1c < 1 >)
   H1. I am going to read you a list of different types of health insurance coverage. Please tell me if
           (you / TARGET) currently (have/has) any of the following types of insurance. Please exclude
           any health insurance plans that cover only ONE type of service, like plans for dental care or
           prescription drugs.
          (Do you/does TARGET) currently have (READ LIST)?
   IF RESPONDENT ASKS TO SKIP THROUGH INSURANCE QUESTIONS, SAY: I‟m sorry, but I
have to read all of the insurance categories.”
          1 Yes
          2 No
          D (DO NOT READ) Don‟t know
          R (DO NOT READ) Refused

   a.    DELETED
   b.    Health insurance through (your/TARGET‟s) work or union (Probe: This insurance could be
         through COBRA, through a former employer or a retiree benefit.)
   c.    Health insurance through someone else‟s work or union (Probe: This insurance could be
         through COBRA, through a former employer or a retiree benefit.)
   d.    Medicare (PROBE: Medicare is the health insurance for persons 65 years old and over or
         persons with disabilities. This is a red, white and blue card.)
   f.    Veteran's Affairs, Military Health, TRICARE or CHAMPUS
   g.    DELETED
   h.    MassHealth or Medicaid (PROBE: This is a Massachusetts program for low- and moderate-
         income families with children, seniors, and people with disabilities. You may know it as
         CommonHealth, Family Assistance, the Medical Security Program, or the Insurance
         Partnership. (You/TARGET) may have coverage under MassHealth through a health insurance
         plan.)
   i.    Commonwealth Care or CommCare? (PROBE: This is a program that provides insurance at
         either no cost or at subsidized rates for low- and moderate-income adults. (You/TARGET)
         would have coverage under CommCare through a health insurance plan.)
   j.    Commonwealth Choice? This is a program that helps people purchase a health insurance plan.
          (You/TARGET) could obtain coverage under Commonwealth Choice from the Connector or
         directly from a health insurance plan. The Connector is a state agency that helps
         Massachusetts residents find health insurance coverage.
   k.    A qualifying student health insurance plan? (PROBE: A QSHIP is a health insurance plan that
         is sponsored by a college or university.)
   l.    Health insurance bought directly by (you / TARGET) (PROBE: For example, bought directly
         from Blue Cross Blue Shield or another company or bought through an insurance broker.)
   m.    Health insurance bought directly by someone else




                                                  -9-
(ASK Q.H1ba IF Q.H1b = 1)
H1ba. Is this an individual policy or is it a family policy?
      (READ IF NECESSARY: The health insurance through (your/TARGET‟s) work or
      union?)

      1   Individual policy
      2   Family policy (covers more than one person)
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK IF H1c=1 & TAGE<=26)
H1ca. Is this through (your/TARGET‟s) parent or guardian?
      (READ IF NECESSARY: The health insurance through someone else‟s work or
      union?)

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK IF H1m=1)
H1ma. Is this an individual policy or is it a family policy?
       (READ IF NECESSARY: The health insurance bought directly by someone else?)

      1   Individual policy
      2   Family policy (covers more than one person)
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK IF H1m=1 & TAGE<=26)
H1mb. Is this through your/TARGET‟s parent or guardian?
      (READ IF NECESSARY: The health insurance bought directly by someone else?)

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK IF H1a, H1b, H1c, H1d, H1e, H1f, H1g, H1h, H1i, H1j, H1k, H1l, H1m ALL=2)
H1n. Do (you/TARGET) currently receive care through the Free Care Program? PROBE: This used
      to be called the Uncompensated Care Pool and is now called the Health Safety Net. You may
      know it as CareNet

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused




                                            -10-
(ASK IF ALL IN H1=2, D, OR R)
H2. Do you currently have any other type of insurance? (DO NOT READ, ALLOW MULTIPLE)
      1   Workers compensation for specific injury/illness
      2   Employer pays for bills, but not an insurance policy
      3   Family member pays out of pocket for any bills
      4   Other Non Insurance Payment Source
      5   Indian Health Service (IHS)
      7   Other Insurance (SPECIFY) __________
      N   No other insurance
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(IF Q.H1 = 2, D OR R TO ALL AND Q.H2 = 1-4 ONLY, READ:)
For the purposes of this survey, we‟ll assume that (you do/TARGET does) not have health
insurance.”
NOW GO TO Q.H6
IF H2=5 ONLY SKIP TO H3C

(ASK Q.H3 IF Q.H1 = 2, D, R FOR ALL AND Q.H2 = N, D OR R)
INSERT “you do” IF Q.S10 = 1
INSERT “NAME/INITIALS/RELATIONSHIP does…” IF Q.S10 = 2
H3. Just to be sure I have this right, (you do/TARGET does) not have health insurance coverage. Is
that correct?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused




                                              -11-
(ASK Q.H3a IF Q.H3 = 2)
INSERT “you” IF Q.S10 = 1
INSERT “they” IF Q.S10 = 2
H3a What insurance do (you/they) have? (DO NOT READ, ENTER ONE ONLY) (Probe: if
     you can, it might be helpful to look at (your/their) insurance card to help identify the type of
     insurance.)

      01   DELETED
      02   Health insurance through (your / TARGET‟s) current work or union
      03   Health insurance through someone else‟s current work or union
      04   Medicare
      05   Railroad Retirement Plan
      06   Veteran's Affairs, Military Health, TRICARE or CHAMPUS
      07   Indian Health Service
      08   MassHealth or Medicaid
      09   Commonwealth Care or CommCare
      10   Commonwealth Choice
      11   Student health plan
      12   Health insurance bought directly by (you / TARGET)
      13   Health insurance bought directly by someone else
      14   Free Care Program /Health Safety Net
      15   Workers compensation for specific injury/illness
      16   Employer pays for bills, but not an insurance policy
      17   Family member pays out of pocket for any bills
      18   Other Non Insurance Payment Source
      97   Other Insurance (SPECIFY) __________
      DD   (DO NOT READ) Don‟t know
      RR   (DO NOT READ) Refused

(IF Q.H3a = 15-18, READ:)
INSERT “you do” IF Q.S10 = 1
INSERT “TARGET does” IF Q.S10 = 2
For the purposes of this survey, we‟ll assume that (you do/TARGET does) not have health
insurance.
NOW GO TO Q.H6

(ASK Q.H3b IF Q.H3a = DD OR RR)
INSERT “you/your” IF Q.S10 = 1
INSERT “they/their” IF Q.S10 = 2
H3b When (you/they) go to a doctor, health clinic, or hospital, does anyone else pay for some or all
     of (your / their) medical bills?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused




                                                -12-
(ASK Q.H3c ------IF Q.H2=5 OR Q.H1n = 1 ONLY OR IF Q.H3a = 07 OR 14)
IF Q.H2 = 5 OR Q.H3a = 07, INSERT “Indian Health Service”
IF Q.H1n = 1 OR Q.H3a = 14, INSERT “Free Care”)
INSERT “you receive/your/you” IF Q.S10 = 1
INSERT “TARGET receives/TARGET‟s/they” IF Q.S10 = 2
H3c. I understand that (you receive / TARGET receives) services through the (Indian Health
      Service/Free Care Program). In addition to this, does anyone else pay for (your / TARGET‟s)
      bills when (you/they) go to a doctor or hospital?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(IF Q.H3c = 2, D, OR R, READ:)
IF Q.H1g = 1 OR Q.H3a = 07, INSERT “Indian Health Service”
IF Q.H1n = 1 OR Q.H3a = 14, INSERT “Free Care” Program)
INSERT “you do” IF Q.S10 = 1
INSERT “TARGET does” IF Q.S10 = 2
For the purposes of this survey, (Indian Health Service/Free Care Program) is not
considered comprehensive insurance. For our survey, we‟ll assume that (you do/TARGET
does) not have health insurance.
NOW GO TO Q.H6




                                             -13-
(ASK Q.H4 IF Q.H3c = 1)
H4. And who is that?
     (DO NOT READ, ENTER ONE ONLY)

      01   DELETED
      02   Health insurance through (your / TARGET‟s) work or union
      03   Health insurance through someone else‟s work or union
      04   Medicare
      05   Railroad Retirement Plan
      06   Veteran's Affairs, Military Health, TRICARE or CHAMPUS
      07   Indian Health Service
      08   MassHealth or Medicaid
      09   Commonwealth Care or CommCare
      10   Commonwealth Choice
      11   Student health plan
      12   Health insurance bought directly by (you / TARGET)
      13   Health insurance bought directly by someone else
      14   Free Care /Health Safety Net
      15   Workers compensation for specific injury/illness
      16   Employer pays for bills, but not an insurance policy
      17   Family member pays out of pocket for any bills
      18   Other Non Insurance Payment Source
      97   Other Insurance (SPECIFY) __________
      DD   (DO NOT READ) Don‟t know
      RR   (DO NOT READ) Refused

(IF Q.H4 = 07 OR 14-18, READ:)
INSERT “you do” IF Q.S10 = 1
INSERT “TARGET does” IF Q.S10 = 2
For purposes of this survey, we‟ll assume (you do/TARGET does) not have insurance.
NOW GO TO Q.H6

(ASK Q.H-4a IF Q.H3a = 2 OR 3 OR Q.H4 = 2 OR 3)
INSERT “your” IF Q.S10 = 1
INSERT “TARGET‟s” IF Q.S10 = 2
H4a. Is this an individual policy or is it a family policy?
     (READ IF NECESSARY IF Q.H3a OR Q.H4 = 2: The health insurance through
     (your/TARGET‟s) work or union?)
     (READ IF NECESSARY IF Q.H3a OR Q.H4 = 3: The health insurance through
     someone else‟s work or union?)

      1    Individual policy
      2    Family policy (covers more than one person)
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused




                                             -14-
  (ASK Q.H4b IF Q.H3a OR Q.H4 = 13 AND IF TARGET<=26 [Q.S6 = <26 OR
  Q.S6(b-j) = <26])
  INSERT “your” IF Q.S10 = 1
  INSERT “TARGET‟s” IF Q.S10 = 2
  H4b. Is this through (your/TARGET‟s) parent or guardian?
       (READ IF NECESSARY: The health insurance bought directly by someone else?)

         1   Yes
         2   No
         D   (DO NOT READ) Don‟t know
         R   (DO NOT READ) Refused

SETUP2

  P.N.: CREATE VARIABLES FOR INSURANCE STATUS to use in rest of survey

         TINS =1 if TARGET insured (Q.H1a-f = 1 OR Q.H1h-m = 1 OR H2 = 7 OR
         H3a = 01-05, 08-13 OR H4 = 10-05, 08-13)
         TINS = 0 if TARGET not insured ([Q.H1 = 2, D, OR R TO ALL AND Q.H2 =
         1-4 AND H3 = 2] OR [Q.H3a = 15-18 OR Q.H3c = 2, D, OR R OR Q.H4 = 07
         OR 14-18])
         TESI = 1 IF TARGET HAS INSURANCE THROUGH OWN WORK OR
         UNION (Q.H1b = 1 OR Q.H3a = 02 OR Q.H4 = 02)

  (ASK IF TINS=1)
  IF TAGE>=1 USE 1ST VERBIAGE IN PARENS
  IF TAGE<1 USE 2ND VERBIAGE IN PARENS
  INSERT “Have you” IF Q.S10 = 1
  INSERT “Has TARGET ” IF Q.S10 = 2
  H5. [(Have you/Has TARGET) had insurance coverage for all of the past 12 months?]
       [Has TARGET had insurance coverage for all of the time since he/she was born?]

         1   Yes
         2   No
         D   (DO NOT READ) Don‟t know
         R   (DO NOT READ) Refused

  (ASK Q.H6 IF TINS = 0 OR Q.H5 = 2)
  INSERT “you” IF Q.S10 = 1
  INSERT “TARGET ” IF Q.S10 = 2
  H6. How many months during the past 12 months were (you / TARGET) without health insurance
       coverage?

         __________ months (RANGE 1-12)
         00 Less than 1 month
         DD (DO NOT READ) Don‟t know
         RR (DO NOT READ) Refused




                                              -15-
(ASK Q.H7 IF TINS = 0)
INSERT “you” IF Q.S10 = 1
INSERT “TARGET ” IF Q.S10 = 2
H7. How long has it been since (you/TARGET) had any health insurance?
     (PROBE FOR MONTHS IF LESS THAN 2 YEARS)

      01   ANSWER GIVEN IN YEARS __________# (2-50) years
      02   ANSWER GIVEN IN MONTHS__________# (1-24) months
      00   Less than 1 month
      NN   NEVER HAD COVERAGE
      DD   (DO NOT READ) Don‟t know
      RR   (DO NOT READ) Refused

(ASK Q.H8 IF TINS = 0)
INSERT “you” IF Q.S10 = 1
INSERT “TARGET ” IF Q.S10 = 2
(SCRAMBLE ITEMS)
H8. I‟m going to read a list of reasons that people sometimes give for why they don‟t have health
     insurance. Please tell me if these are reasons that (you/target) (do/does) not have health
     insurance? How about (INSERT)?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

a.    The person in family who had health insurance lost job or changed employers
b.    The person in family who had health insurance is no longer part of the family because
      of divorce, separation or death
c.    Family member‟s employer does not offer coverage or not eligible for employer‟s
      coverage
d.    Lost eligibility for MassHealth or CommCare
e.    Cost is too high
g.    Don‟t need insurance
h.    Don‟t know how to get insurance
i.    Traded health insurance for another benefit or higher pay
j.    Some other reason (SPECIFY) __________________




                                              -16-
(ASK Q.H9 IF Q.H7 = 01, 02, 00, OR DD)
INSERT “you” IF Q.S10 = 1
INSERT “TARGET ” IF Q.S10 = 2
(ASK ITEMS 02, 05, 09, 10, 12 if TAGE>17)
(ASK ITEM 11 if TAGE>15)

H9   Thinking back to the last time (you/TARGET) had health insurance, what type of insurance did
      (you/TARGET) have?
     (DO NOT READ LIST. UP TO 5 RESPONSES ALLOWED)

     01   DELETED
     02   Health insurance through (your/TARGET‟s) work or union
     03   Health insurance through someone else‟s work or union
     04   Medicare
     05   Railroad Retirement Plan
     06   Veteran's Affairs, Military Health, TRICARE or CHAMPUS
     07   Indian Health Service
     08   MassHealth or Medicaid
     09   Commonwealth Care or CommCare
     10   Commonwealth Choice
     11   Student health plan
     12   Health insurance bought directly by you
     13   Health insurance bought directly by someone else
     14   Free Care Program /Health Safety Net
     15   Other Non Insurance Payment Source
     95   Other Insurance#1 (SPECIFY) __________
     96   Other Insurance#2 (SPECIFY) __________
     97   Other Insurance#3 (SPECIFY) __________
     98   Other Insurance#4 (SPECIFY) __________
     99   Other Insurance#5 (SPECIFY) __________
     DD   (DO NOT READ) Don‟t know
     RR   (DO NOT READ) Refused

(ASK Q.H10 IF TINS = 0 OR Q.H5 = 2)
INSERT “you” IF Q.S10 = 1
INSERT “TARGET ” IF Q.S10 = 2
H10 At any time in the past 12 months, did (you / TARGET) receive care under the Free Care?
     (PROBE: This used to be called the Uncompensated Care Pool and is now called the Health
     Safety Net. You may know it as CareNet)

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                            -17-
    The next questions concern the health insurance that the other people in your household have at this
time. In answering these questions, please exclude any health insurance plans that cover only ONE type
of service, like plans for dental care or prescription drugs.

   (PN: PROCEED DOWN HH ROSTER LIST. ASK Q.S13 THRU Q.I7 IN A SERIES
   FOR EACH PERSON IN HH EXCEPT TARGET)

   INSERT “Do you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “Does your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
   FROM Q.S7(b-j) IF OTHER PERSON IN HH
   S13. Do you/ Does your (RELATIONSHIP FROM Q.S8[b-j] [INSERT AGE/GENDER FROM
        Q.S6[b-j] AND S7 [b-j]) currently have health insurance?

         1    Yes                                SKIP TO I1
         2    No                                 SKIP TO I3
         D    (DO NOT READ) Don‟t know           REPEAT FOR NEXT PERSON HH ROSTER
         R    (DO NOT READ) Refused              REPEAT FOR NEXT PERSON HH ROSTER




                                                  -18-
  (ASK Q.I1 IF Q.S13 = 1)
  (ASK ITEM c IF I1b < 1 >)
  (ASK ITEMS b, i, j, and l if S6>17)
  (ASK ITEM l IF I1b AND I1c < 1 >)
  (ASK ITEM m IF I1l AND I1b AND I1c <1 >)
  (ASK ITEM k if S6>15 AND </=64 OR I1b AND I1C < 1 >)

  INSERT “are you” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “is this person” IF OTHER PERSON IN HH
  (UP TO 5 RESPONSES ALLOWED)
  I1. What type of health insurance (are you/is this person) covered by? Is it (INSERT)?

          1 Yes
          2 No
          D (DO NOT READ) Don‟t know
          R (DO NOT READ) Refused
   IF RESPONDENT ASKS TO SKIP THROUGH INSURANCE QUESTIONS, SAY: I‟m
sorry, but I have to read all of the insurance categories.”

  a.   DELETED
  b.   Health insurance through (your/his/her) work or union? (IF TAGE<18, ADD
        PROBE FOR FIRST ADULT: This insurance could be COBRA, through a former employer or
       a retiree benefit.)
  c.   Health insurance through someone else‟s work or union (Probe: This insurance could be
        through COBRA, a former employer or a retiree benefit..)
  d.   Medicare (IF TAGE<18, ADD PROBE FOR FIRST ADULT: Medicare is the
       health insurance for persons 65 years old and over or persons with disabilities. This is
       a red, white and blue card.)
  f.   Veteran's Affairs, Military Health, TRICARE or CHAMPUS
  g.   DELETED
  h.   MassHealth or Medicaid (PROBE: This is a Massachusetts program for low- and moderate-
        income families with children, seniors, and people with disabilities. You may know it as
        CommonHealth, Family Assistance, the Medical Security Program, or the Insurance
        Partnership. (You/he/she) may have coverage under MassHealth through a health insurance
        plan.)
  i.   Commonwealth Care or CommCare (IF TAGE<18, ADD PROBE FOR FIRST
       ADULT: This is a program that provides insurance at either
       no cost or at subsidized rates for low- and moderate-income adults. (You/he/she)
       would have coverage under CommCare through a health insurance plan.
  j.   Commonwealth Choice? This is a program that helps people purchase a health insurance plan.
         (You/TARGET) could obtain coverage under Commonwealth Choice from the Connector or
        directly from a health insurance plan. The Connector is a state agency that helps
        Massachusetts residents find health insurance coverage.
  k.   A qualifying student health insurance plan (IF TAGE<18, ADD PROBE FOR FIRST HH
       MEMBER AGE >16: This is a health insurance plan that is sponsored by a college or
       university.)
  l.   Health insurance bought directly by (you/him/her) (IF TAGE<18, ADD PROBE
       FOR FIRST ADULT: For example, bought directly from Blue Cross Blue Shield or another
              company or bought through an insurance broker.)
  m.   Health insurance bought directly by someone else




                                               -19-
(ASK IF Ia-Im ALL=2))
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “they” IF OTHER PERSON IN HH
I1m. Do (you/they) currently receive care through Free Care?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK Q.I1bb IF Q.I1b = 1)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “he” IF OTHER PERSON IN HH AND Q.S7 = 1
INSERT “she” IF OTHER PERSON IN HH AND Q.S7 = 2
I1bb. Is the insurance through work an individual policy or is it a family policy?
      (READ IF NECESSARY: The health insurance through (your/his/her) work or
      union?)

      1   Individual policy
      2   Family policy (covers more than one person)
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK IF ALL IN I1=2, D, OR R)
INSERT “Do you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Does he” IF OTHER PERSON IN HH AND Q.S7 = 1
INSERT “Does she” IF OTHER PERSON IN HH AND Q.S7 = 2
I2. (Do you/Does he/she) currently have any other type of insurance?
     (DO NOT READ, SELECT ANSWERS)

     1    Workers compensation for specific injury/illness
     2    Employer pays for bills, but not an insurance policy
     3    Family member pays out of pocket for any bills
     4    Other Non Insurance Payment Source
     5    Indian Health Service (IHS)
     6    Other Insurance (SPECIFY)__________
     7    No other insurance
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                              -20-
(IF Q.I2 = 5 OR Q.I1m = 1 ONLY, READ:)
INSERT “Free Care Program”, IF Q.I1n = 1
INSERT “Indian Health Service”, IF Q.I2 = 5
The (Free Care /Indian Health Service) is not considered comprehensive insurance
for the purposes of this survey”
NOW GO TO Q.I3

(IF Q.I2 = 1-4 ONLY, READ:)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “he” IF OTHER PERSON IN HH AND Q.S7 = 1
INSERT “she” IF OTHER PERSON IN HH AND Q.S7 = 2
For the purposes of this survey, we‟ll assume that (you/he/she) does not have health
insurance.
NOW GO TO Q. I5

(ASK Q.I3 IF Q.S13 = 2 OR Q.I1a-f OR h-m = 2 TO ALL OR Q.I2 = 7,D,R)
INSERT “You do” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) does “ IF OTHER PERSON IN HH
I3. Just to be sure I have this right. (You do/RELATIONSHIP FROM Q.S8[b-j] [INSERT
    AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) does) not have health insurance coverage. Is
    that correct?

      1    Yes
      2    No
      D    (DO NOT READ)
      R    (DO NOT READ)




                                               -21-
(IF Q.I3 = 2 ASK Q.I3a)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “he” or “him” IF OTHER PERSON IN HH AND Q.S7 = 1
INSERT “she” or “her” IF OTHER PERSON IN HH AND Q.S7 = 2
I3a. What insurance do you/they have? (Probe: If you can, it might be helpful to look at
           your/their insurance card to help identify the type of insurance.)
       (DO NOT READ, ENTER ONE ONLY)

      01   DELETED
      02   Health insurance through (your / TARGET‟s) current work or union
      03   Health insurance through someone else‟s current work or union
      04   Medicare
      05   Railroad Retirement Plan
      06   Veteran's Affairs, Military Health, TRICARE or CHAMPUS
      07   Indian Health Service
      08   MassHealth or Medicaid
      09   Commonwealth Care or CommCare
      10   Commonwealth Choice
      11   Student health plan
      12   Health insurance bought directly by (you / TARGET)
      13   Health insurance bought directly by someone else
      14   Free Care Program /Health Safety Net
      15   Workers compensation for specific injury/illness
      16   Employer pays for bills, but not an insurance policy
      17   Family member pays out of pocket for any bills
      18   Other Non Insurance Payment Source
      97   Other Insurance (SPECIFY) __________
      DD   (DO NOT READ) Don‟t know
      RR   (DO NOT READ) Refused

IF I3a = 07,14-18 , READ:
INSERT “You do” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) does “ IF OTHER PERSON IN HH
For the purposes of this survey, we‟ll assume that (you do/TARGET does) not have health
insurance.
NOW SKIP TO Q.I5




                                              -22-
(ASK Q.I4 IF Q.I1a-f OR h-m = 1 TO ANY OR Q.I2 = 5 OR Q.I3a = 01-06, 08-13)
IF TAGE>=1, USE 1ST VERBIAGE IN PARENS
IF TAGE<1 USE 2ND VERBIAGE IN PARENS
INSERT “Have you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Has your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
I4. [(Have you/Has your RELATIONSHIP FROM Q.S8[b-j] [INSERT AGE/GENDER FROM
      Q.S6[b-j] AND S7 [b-j]) had insurance coverage for all of the past 12 months?]
     [Has your RELATIONSHIP FROM Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j]
      AND S7 [b-j]) had insurance coverage for all of the time since he/she was born?]

     1   Yes
     2   No
     D   (DO NOT READ) Don‟t know
     R   (DO NOT READ) Refused

(ASK IF Q.I3=1 OR Q.I3a=07, 14-18 OR Q.I4=2; ELSE SKIP TO NEXT PERSON OR IF LAST
PERSON SKIP TO SETUP3)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
I5. How many months during the past 12 months were (you / your RELATIONSHIP FROM
      Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) without health insurance
      coverage?

     __________# months (RANGE 1-12)
     LL Less than 1 month
     DD (DO NOT READ) Don‟t know
     RR (DO NOT READ) Refused

IF PERSON IS CURRENTLY INSURED (Q.I1a-f OR h-l = 1 TO ANY OR Q.I2 = 5
OR Q.I3a = 01-06, 08-13) SKIP TO NEXT PERSON OR IF LAST PERSON SKIP TO
SETUP3




                                         -23-
(ASK Q.I6 IF Q.I3 = 2, D, OR R OR Q.I3a = 07, 14-18)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
I6. How long has it been since (you/your RELATIONSHIP FROM Q.S8[b-j] [INSERT
      AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) had any health insurance?
     (PROBE FOR MONTHS IF LESS THAN 2 YEARS)

      01   ANSWER GIVEN IN YEARS __________# (2-50) years
      02   ANSWER GIVEN IN MONTHS __________# (1-24) months
      NN   NEVER HAD COVERAGE
      DD   (DO NOT READ) Don‟t know
      RR   (DO NOT READ) Refused
IF Q.I6 = NN SKIP TO NEXT PERSON OR IF LAST PERSON SKIP TO SETUP3

(ASK Q.I7 IF Q.I6 NE NN) ???
INSERT “you IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j)/he/she “ IF OTHER PERSON IN HH
(ASK ITEMS 02, 04, 08, 09, 11 if TAGE>17)
(ASK ITEM 10 if TAGE>15)

I7.   Thinking back to the last time (you/your RELATIONSHIP FROM Q.S8[b-j] [INSERT
       AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) had health insurance, what type of insurance
       did (you/he/she) have?
      (DO NOT READ, UP TO 5 RESPONSES ALLOWED)
     01 Cobra - DELETED
     02 Health insurance through work or union
     03 Health insurance through someone else‟s work or union
     04 Medicare
     05 Railroad Retirement Plan
     06 Veteran's Affairs, Military Health, TRICARE or CHAMPUS
     07 Indian Health Service
     08 MassHealth or Medicaid
     09 Commonwealth Care or CommCare
     10 Commonwealth Choice
     11 Student health plan
     12 Health insurance bought directly by you/him/her
     13 Health insurance bought directly by someone else
     14 Free Care/Health Safety Net
     15 Other Non Insurance Payment Source
     95 Other Insurance #1(SPECIFY) __________
     96 Other Insurance #2 (SPECIFY) __________
     97 Other Insurance # 3(SPECIFY) __________
     98 Other Insurance # 4 (SPECIFY) __________
     99 Other Insurance #5 (SPECIFY) __________
     DD (DO NOT READ) Don‟t know
     RR (DO NOT READ) Refused
(ASK Q.I8 IF S13=2 OR I1 ALL=2 AND I3=1 OR I3a=17, 14-18)
(ASK Q.I8 IF I4=2)
INSERT “you” IF Q.S10 = 1
INSERT “TARGET” IF Q.S10 = 2


                                           -24-
  I8     At any time in the past 12 months, did (you/your RELATIONSHIP FROM Q.S8[b-j] [INSERT
         AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) receive care under Free Care (PROBE: This
         used to be called the Uncompensated Care Pool and is now called the Health Safety Net. You
         may know it as CareNet)

         1   Yes
         2   No
         D   (DO NOT READ) Don‟t know
         R   (DO NOT READ) Refused

NOW SKIP TO NEXT PERSON OR IF LAST PERSON SKIP TO SETUP3

SETUP3

CREATE VARIABLES FOR INSURANCE STATUS OF TARGET’S SPOUSE/PARTNER
AND/OR PARENT/GUARDIAN

  SESI = 1 IF SPOUSE/PARTNER HAS INSURANCE THROUGH OWN WORK OR
  UNION (Q.S8b-j = 01 or 02 AND [Q.I1b = 1 OR Q.I3a = 02])
  PESI = 1 IF ANY PARENT/GUARDIAN HAS INSURANCE THROUGH OWN
  WORK OR UNION (Q.S8b-j = 04 AND [Q.I1b = 1 OR Q.I3a = 02])
  SFAM=1 IF SPOUSE HAS FAMILY COVERAGE THROUGH OWN WORK OR
  UNION (Q.S8b-j = 01 AND [(Q.I1b = 1 AND I1bb = 2) OR Q.I3a = 02])
  PFAM=1 IF ANY PARENT/GUARDIAN HAS FAMILY COVERAGE THROUGH
  OWN WORK OR UNION (Q.S8b-j = 04 AND [(Q.I1b = 1 AND Q.I1bb = 2) OR
  Q.I3a = 02])




                                                -25-
EMPLOYMENT

INSTRUCTIONS FOR SEQUENCE E1 TO E14:
IF TAGE<15: PROCEED THROUGH ROSTER FOR TARGET‟S PARENTS OR
GUARDIAN
IF TAGE= 15-25: PROCEED THROUGH ROSTER FOR TARGET, TARGET‟S SPOUSE
(IF PRESENT) AND TARGET‟S PARENTS (IF PRESENT)
IF TAGE>25: PROCEED THROUGH ROSTER FOR TARGET & TARGET‟S SPOUSE
(IF PRESENT)

My next questions ask about employment.

I‟d like to start by asking about (you/TARGETRELATIONSHIP FROM Q.S8[b-j] [INSERT
AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j).

FOR SUBSEQUENT PEOPLE: Now I‟d like to ask about (you/TARGET/RELATIONSHIP FROM
Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j).

  INSERT “Are you” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “Is TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
  INSERT “Is your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
  FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
  E1. (Are you /Is TARGET/Is your RELATIONSHIP FROM Q.S8[b-j] [INSERT AGE/GENDER
       FROM Q.S6[b-j] AND S7 [b-j) currently…

        1    Self-employed
        2    Employed by military
        3    Employed by someone else
        4    Unpaid worker for a family business
        5    Retired
        6    Unemployed or not working
        D    (DO NOT READ) Don‟t know
        R    (DO NOT READ) Refused

  (ASK Q.E2 IF Q.E1 = 1-3)
  INSERT “Do you” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “Does TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
  INSERT “Does your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
  FROM Q.S7(b-j)“ IF OTHER PERSON IN HH
  E2. (Do you/Does TARGET/Does your RELATIONSHIP FROM Q.S8[b-j] [INSERT
       AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j) have more than one job, including part-time,
       evening or weekend work?

        1    Yes
        2    No
        D    (DO NOT READ) Don‟t know
        R    (DO NOT READ) Refused




                                               -26-
(ASK Q.E3 IF Q. E2 = 1)
  INSERT “Do you” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “Does TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
  INSERT “Does your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
  FROM Q.S7(b-j)“ IF OTHER PERSON IN HH
  E3. Altogether, how many jobs (do you/does TARGET/ does your RELATIONSHIP FROM
        Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j) have?

       1    2 jobs
       2    3 jobs
       3    4 or more jobs
       D    (DO NOT READ) Don‟t know
       R    (DO NOT READ) Refused

  (ASK Q.E4 IF Q.E1 = 1-3)
  INSERT “Do you/your/you/work” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “Does TARGET/their/he/works” IF PERSON ASKING ABOUT IS “TARGET
  PERSON” AND Q.S7 = 1
  INSERT “Does TARGET/their/she/works” IF PERSON ASKING ABOUT IS “TARGET
  PERSON” AND Q.S7 = 2
  INSERT “Does your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
  FROM Q.S7(b-j)/their/he/she “ IF OTHER PERSON IN HH
  E4. How many hours per week (do you /does TARGET/(does your RELATIONSHIP FROM
       Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j) usually work at
       (your/their) (READ IF E2=1: main) job? IF NEEDED: By main job, I mean the one at which
       (you/he/she) usually (work/works) the most hours.

       __________ hours (1-100)
       DD (DO NOT READ) Don‟t know
       RR (DO NOT READ) Refused

  (ASK Q.E5 IF Q.E2 = 1)
  INSERT “Do you/your” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “Does TARGET/their” IF PERSON ASKING ABOUT IS “TARGET
  PERSON”
  INSERT “Does your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
  FROM Q.S7(b-j)/their“ IF OTHER PERSON IN HH
  E5. How many hours per week (do you /does TARGET/does your RELATIONSHIP FROM
       Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) usually work at
       (your/their) other jobs?

       ________ hours (ENTER # OF HOURS 1-100)
       DD (DO NOT READ) Don‟t know
       RR (DO NOT READ) Refused




                                            -27-
(ASK Q.E6 IF Q.E=1-3)
INSERT “have you/your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “has TARGET/their” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “has your RELATIONSHIP FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j)/their“ IF OTHER PERSON IN HH
E6. How long (have you/has TARGET/has your RELATIONSHIP FROM Q.S8[b-j] [INSERT
      AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) worked for (your/their) (READ IF E2=1:
      main) job?
     PROBE FOR MONTHS IF LESS THAN 2 YEARS

     01 ANSWER GIVEN IN YEARS (ENTER # OF YEARS 2-60)
     02 ANSWER GIVEN IN MONTHS (ENTER # OF MONTHS 1-24)
     LL Less than 1 month
     DD (DO NOT READ) Don‟t know
     RR (DO NOT READ) Refused

(ASK Q.E7 IF Q.E2 = 1)
(IF Q.E1 =1, READ VERBIAGE IN PARENS)
INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j)“ IF OTHER PERSON IN HH
E7. Counting all locations where this employer operates, are there more than 50 people working for
       (your/TARGET‟s/your RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER FROM
       Q.S6[b-j] AND S7 [b-j]) employer?
      (Including (yourself/TARGET/your RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT
       AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) are there more than 50 people working for
       this business?)

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                             -28-
(ASK Q.E8 IF Q.E7 = 2)???
INSERT “business” IF Q.E1 = 1; OTHERWISE, INSERT “employer”
INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j)“ IF OTHER PERSON IN HH
E8. Which category best represents the total number of persons who work for (your/TARGET‟s
     your RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND
     S7 [b-j]) (employer/business)? Would it be…?

     1    Just one
     2    Between 2 and 10
     3    Between 11 and 50
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused

(ASK Q.E9 IF Q.E7 = 1)
INSERT “business” IF Q.E1 = 1; OTHERWISE, INSERT “employer”
INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j)“ IF OTHER PERSON IN HH
E9. Which category best represents the total number of persons who work for (your/TARGET‟s/
     your RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND
     S7 [b-j]) (employer/business)? Would it be…?

     1    Between 51 and 100
     2    Between 101 and 500
     3    Between 501 and 1000
     4    Over 1000
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                           -29-
(ASK Q.E10 IF TESI = 0 OR IF SESI = 0 OR IF PESI = 0)
INSERT “you work/your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET works/their” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) works/their“ IF OTHER PERSON IN HH
INSERT “main” if E2=1
E10. Does the place where (you work/TARGET works/your RELATIONSHIP‟s FROM Q.S8[b-j]
     [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j] works) at (your/their) (main) job
     offer health insurance as a benefit to any of its employees? INTERVIEWER: ASK ABOUT
     PRIMARY EMPLOYER IF HAVE MULTIPLE EMPLOYERS

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused

(ASK Q.E11 IF TESI = 0 OR IF SESI = 0 OR IF PESI = 0
ASK E11 IF E10=1,D,R)
INSERT “Are you/your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Is TARGET/their” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “Is your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) /their“ IF OTHER PERSON IN HH
E11. (Are you /Is TARGET/Is your RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER
      FROM Q.S6[b-j] AND S7 [b-j]) offered health insurance through (your/their) work? (Probe:
      Could (you/they) get health insurance through (your/their) work?

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                            -30-
(ASK E12 IF TARGET AND TESI=1 AND H1ba=1,D,R OR SPOUSE AND SESI=1 AND
I1bb=1,D,R OR TARGET‟S PARENT AND PESI=1 AND I1bb=1,D,R
ASK E12 IF E11=1, D, R)
INSERT “you/your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET/their” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) /their“ IF OTHER PERSON IN HH
E12. Earlier you mentioned that (you / TARGET/ your RELATIONSHIP‟s FROM Q.S8[b-j]
      [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j]) had health insurance coverage
      through (your/their) employer. Could dependents be covered under that health insurance?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

ASK IF TAGE OR S6 > 16
INSERT “Are you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Is TARGET” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “Is your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
E13. (Are you/Is TARGET/Is your RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER
      FROM Q.S6[b-j] AND S7 [b-j]) a veteran of the United States military?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK EVERYONE)
INSERT “Are you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Is TARGET” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
INSERT “Is your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
E14. (Are you/Is TARGET/Is RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER
      FROM Q.S6[b-j] AND S7 [b-j]) currently a full-time student?
     (IF NECESSARY: greater than three-fourths time)?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused




                                             -31-
ACCESS, USE AND COST

  (ASK EVERYONE)
  INSERT “your/you/go/are” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “TARGET‟s/goes/he/she/is/his/her” IF PERSON ASKING ABOUT IS
  “TARGET PERSON”
  A1. My next questions ask about [your/ TARGET‟s] recent health care experiences. Is there a
       place where [you/ TARGET‟s] usually [go/goes] when [you/(he/she)] [are/is] sick or when
       [you/(he/she)] need advice about [your/(his/her)] health?

        1   Yes
        2   No
        D   (DO NOT READ) Don‟t know
        R   (DO NOT READ) Refused

  (ASK Q.A2 IF Q.A1 = 1)
  A2. What kind of place is it? Is it….? (READ LIST. ENTER ONE ONLY)

        1   A doctor‟s office or private clinic
        2   A community health center or other public clinic
        3   A hospital outpatient department
        4   A hospital emergency room
        5   An urgent care center that is not part of a community health center
        6   Or, some other place
        7   (DO NOT READ) Doesn‟t go to one place most often
        D   (DO NOT READ) Don‟t know
        R   (DO NOT READ) Refused

  (ASK EVERYONE)
  INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
  A3. The next questions are about the health care [you/ TARGET] received in the past 12 months. In
        the past 12 months, how many times did [you/ TARGET] receive care in a hospital emergency
        room?
       (READ LIST IF NECESSARY. ENTER ONE ONLY)

        0   None
        1   1 time
        2   2 times
        3   3 times
        4   More than 3 times
        D   (DO NOT READ) Don‟t know
        R   (DO NOT READ) Refused




                                                -32-
(ASK Q.A3a IF Q.A3 = 1-4)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
INSERT “TARGET‟s parent IF TAGE<18)
A3a. The last time (you/TARGET) went to a hospital emergency room, was it for a condition that
     (you/TARGET/TARGET‟S parent) thought could have been treated by a regular doctor if he or
     she had been available?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(ASK Q.A3b IF Q.A3a = 1)
 A3b. I'm going to read you a list of reasons why some people go to the emergency room.
  Please tell me if any of these were important reasons for (your/TARGET‟s) last visit to
  a hospital emergency room. (INSERT) Was this an important reason?

    1.   Yes
    2.   No
    D    DK
    R    Refused

     a. (You were/TARGET was) unable to get an appointment at the doctor's office or
           clinic as soon as (you/TARGET) thought one was needed
     b. (You/TARGET) needed care after normal operating hours at the doctor's office or
clinic
     c. (You/TARGET) owed money to the doctor's office or clinic
     d. It was more convenient to go to the hospital emergency room


(ASK EVERYONE)
(IF TFEM=1 & TAGE>15 AND <50, INSERT “other than to have a baby”)
INSERT “were you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “was TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
A4. In the past 12 months, (were you/ was TARGET] a patient in a hospital overnight (other than to
      have a baby)?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused




                                               -33-
(ASK EVERYONE)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
INSERT “or pediatrician” IF TAGE<18
A5. In the past 12 months, how many times did [you/ TARGET] visit a general doctor who treats a
      variety of illnesses? For example, a doctor (or pediatrician) in general practice, family
      medicine or internal medicine. Please do not include care you received when you were
      hospitalized overnight or in hospital emergency rooms.
     (READ LIST IF NECESSARY. ENTER ONE ONLY)

      0    None
      1    1 time
      2    2 times
      3    3 times
      4    More than 3 times
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(ASK Q.A5a IF Q.A5 = 1-4)
(IF A5 = 1, INSERT “Was this visit”; IF A5 = 2-4, INSERT “Were any of those visits”)
A5a. (Was this visit/Were any of those visits) for a check-up, physical examination or for other
      preventive care?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(ASK EVERYONE)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
A6. In the past 12 months, did [you/ TARGET] visit a specialist? Specialists are doctors like
     surgeons, heart doctors, allergy doctors, skin doctors and others who specialize in one area of
     health care. Please do not include care [you/ TARGET] received when [you/ TARGET] were
     hospitalized overnight or in hospital emergency rooms.

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused




                                               -34-
(ASK EVERYONE)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
A7. In the past 12 months, did [you/ TARGET] see a dentist or a dental hygienist?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK EVERYONE)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
A8. In the past 12 months, did [you/ TARGET] take any prescription drugs?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK EVERYONE)
INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
INSERT “Is your RELATIONSHIP‟s FROM Q.S8(b-j)/AGE FROM Q.S6(b-j)/GENDER
FROM Q.S7(b-j) “ IF OTHER PERSON IN HH
FOR ITEMS a & b INSERT “for TARGET” IF TAGE<18
(SCRAMBLE)
A9. Still thinking about the past 12 months, was there any time that [you/ TARGET/
     RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-
     j]] did (INSERT) because of cost?

      1   Yes
      2   No
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

a.    Not fill a prescription for medicine (for TARGET
c.    Not get doctor care that (you/TARGET) needed
d.    Not get specialist care that (you/TARGET) needed (IF NEEDED: Specialists are doctors like
      surgeons, heart doctors, allergy doctors, skin doctors and others who specialize in one area of
      health care.)
e.    Not get dental care that (you/TARGET) needed




                                               -35-
ASK EVERYONE
A9b. Next, I‟m going to read you a list of problems some people experience when they try to get
health care. Please tell me if (you have/TARGET has) had these problems in the past 12          months.
(INSERT). Has this happened to (you/TARGET) in the past 12 months?

                1       Yes
                2       No
                D       (DO NOT READ) Don‟t know
                R       (DO NOT READ) Refused

a. (You were/TARGET was) unable to get an appointment at the doctor's office or clinic as soon as
       (you/TARGET) thought one was needed
b. (You were/TARGET was) told by a doctor‟s office or clinic that they weren‟t accepting       patients
       with (your/TARGET‟s) type of health insurance.
c. (You were/TARGET was) told by a doctor‟s office or clinic that they weren't accepting new patients.

   (ASK EVERYONE)
   INSERT “you” when respondent is TARGET and TARGET‟s TFAM_COUNT= 1
   INSERT “your family” when respondent is TARGET and TARGET‟s TFAM_COUNT> 1
   INSERT “TARGET” when TARGET is not respondent and TARGET‟s TFAM_COUNT=1
   INSERT “TARGET‟s FAMILY” when TARGET is not respondent and TARGET‟s
   TFAM_COUNT> 1
   A10. "My next questions are about the health care costs that [you/(your
family)/TARGET/TARGET's family) had in the past 12 months. First, I'd like to ask about how much
was spent "out of pocket" for health care in the past 12 months for [you/TARGET] (and your
family/and[his/her] family). "Out of pocket" is the amount of money you pay that is not covered by
any insurance or special assistance that you might have. It does not include any premiums that you pay
for your health insurance or any health care costs that will be reimbursed. Please include costs for
prescription medicines, dental and vision care, and all other medical expenses, including for doctors,
hospitals, tests and equipment. Please include co-pays in your estimate.

         "How much was spent "out of pocket" for health care in the past 12 months for [you/TARGET]
          (and your family/and[his/her] family)? Was it....?"
         (READ LIST. ENTER ONE ONLY)

         1    Less than $200
         2    $200 to under $500
         3    $500 to under $1,000
         4    $1,000 to under $3,000
         5    $3,000 to under $5,000
         6    $5,000 or more
         7    (DO NOT READ) DID NOT USE CARE
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused




                                                  -36-
   (ASK EVERYONE)
   INSERT “you” when respondent is TARGET and TARGET‟s TFAM_COUNT= 1
   INSERT “your family” when respondent is TARGET and TARGET‟s TFAM_COUNT> 1
   INSERT “TARGET” when TARGET is not respondent and TARGET‟s TFAM_COUNT=1
   INSERT “TARGET‟s FAMILY” when TARGET is not respondent and TARGET‟s
   TFAM_COUNT> 1
   A11. In the past 12 months, did [you/your family/TARGET/TARGET's family] have any problems
paying or [were you/were they] unable to pay any of [your/their] medical bills? This would include
doctor or hospital bills, dentist bills, bills for prescription drugs, nursing home bills, or home care bills.

          1    Yes
          2    No
          D    (DO NOT READ) Don‟t know
          R    (DO NOT READ) Refused


HEALTH STATUS

My next questions are about (your/TARGET‟s) health.

   (ASK EVERYONE)
   INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   HS1. Would you say (your / TARGET‟s) health, in general, is excellent, very good, good, fair, or
        poor?

          1    Excellent
          2    Very good
          3    Good
          4    Fair
          5    Poor
          D    (DO NOT READ) Don‟t know
          R    (DO NOT READ) Refused

   (ASK EVERYONE)
   INSERT “Are you/your” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “Is TARGET/his/her IF PERSON ASKING ABOUT IS “TARGET PERSON”
   HS2. (Are you/ Is TARGET) limited in any way in (your/his/her) activities because of a physical,
         mental, or emotional problem?

          1    Yes
          2    No
          D    (DO NOT READ) Don‟t know
          R    (DO NOT READ) Refused




                                                      -37-
PUBLIC COVERAGE

Now I have a few questions about insurance programs available through the state of Massachusetts for
those who are uninsured.

   P.N. - FOR TARGET<18 ASK ABOUT “TARGET’S PARENTS”

   (ASK P1 THROUGH P4 IF Q.H3=1 OR Q.H2=1-5 ONLY OR Q.H3c=2,D, OR R OR Q.H4=07
   OR14-18)
   INSERT “Have you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “Has TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   INSERT “Has TARGET‟s parent IF TAGE<18)
   P1. (Have you /Has TARGET/Has TARGET‟s parents) ever asked for or been given information
        about any of the programs available in Massachusetts for people who are uninsured? This
        would include MassHealth, Commonwealth Care or Commonwealth Choice, among others.

         1    Yes
         2    No
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused


   INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET/he/she” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   INSERT “TARGET‟s parent/he/she/TARGET” IF TAGE<18)
   P2. If (you / TARGET/TARGET‟s parents) learned (you /(she/he) /TARGET) were eligible for
        health coverage through one of these programs, would (you / he/she) enroll (//TARGET)?

         1    Yes
         2    No
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

   (ASK P3 IF P2=2)
   INSERT “you/your” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET/he/she/her/his” IF PERSON ASKING ABOUT IS “TARGET
   PERSON”
   INSERT “TARGET‟s parent/he/she/her/his/TARGET” IF TAGE<18)
   P3. If (you / TARGET/TARGET‟s parents) learned (you/ (she/he)/ TARGET) were eligible for
        health coverage through one of these programs at no cost to (you / TARGET) or (your /her/his)
        family, would (you /she/he) enroll (//TARGET)?

         1    Yes
         2    No
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused



   INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   ALLOW MULTIPLE RESPONSES



                                                 -38-
 P4.   I‟m going to read you a list of reasons people sometimes give for not enrolling in programs.
        Please tell me which of these are important reasons (you / TARGET) are not enrolled in one of
        the programs available in Massachusetts for people who are uninsured?

       01   Have other insurance
       02   Cost was too high
       03   Don‟t like the benefits package
       04   Too much hassle/paperwork
       05   Don‟t need or don‟t want insurance
       06   Not eligible for coverage
       07   Don‟t know about programs
       08   Don‟t know how to enroll in programs
       09   Don‟t want to enroll in a public program
       97   Something else (SPECIFY) __________________
       DD   (DO NOT READ) Don‟t know
       RR   (DO NOT READ) Refused

HEALTH REFORM

 (ASK EVERYONE)
 HR1. Now I have some general questions about health insurance in Massachusetts. As you may
      know, Massachusetts has a law that is aimed at providing health insurance for all
      Massachusetts residents. In general, do you support or oppose this Massachusetts law?

       1    Support
       2    Oppose
       D    (DO NOT READ) Don‟t know
       R    (DO NOT READ) Refused

 (ASK EVERYONE)
 HR2. As part of that law, Massachusetts now requires that residents of the state either obtain health
      insurance or pay a fine. The requirement applies to everyone except people that a state agency
      determines can‟t afford the cost of a policy. Have you heard or read about this requirement? It
      is called the individual mandate.

       1    Yes
       2    No
       D    (DO NOT READ) Don‟t know
       R    (DO NOT READ) Refused




                                               -39-
   (ASK Q.HR3 IF Q.HR2 = 1 AND TAGE >18)
   INSERT “your/you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET‟s/TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   HR3. For the next question, I‟m going to read you a list of ways the individual mandate may have
         affected (your (your/TARGET‟s) current health insurance coverage. Please tell me when I get
         to the one that describes the way the individual mandate affected (you/TARGET).

         1    The individual mandate had no effect because (you/TARGET) already had
              coverage
         2    (You/TARGET) obtained coverage because of the individual mandate.
         3    (You/TARGET) tried to obtain coverage because of the individual mandate but
              could not find coverage (you/he/she) could afford
         4    (You/TARGET) decided not to obtain coverage and will just pay the penalty.
         5    Something else (SPECIFY) __________
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

BACKGROUND

Now, I‟d like to ask a few questions to help us describe the people who participated in our survey.

   (ASK EVERYONE)
   INSERT “Are you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   D1. (Are you/TARGET) Mexican, Puerto Rican, Cuban or another Hispanic or Latino group?

         1    No, not of Hispanic origin
         2    Yes, Mexican, Mexican American, Chicano
         3    Yes, Puerto Rican
         4    Yes, Cuban
         5    Yes, other Spanish/Hispanic/Latino
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused

   (ASK EVERYONE)
   INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   D2. Which one or more of the following would you say is (your/TARGET‟s) race?
        (READ LIST. ENTER ALL THAT APPLY)

         1    White
         2    Black or African American
         3    Asian
         4    Native Hawaiian or other Pacific Islander
         5    American Indian or Alaska Native
         7    Some other race (SPECIFY) ______________
         D    (DO NOT READ) Don‟t know
         R    (DO NOT READ) Refused




                                                   -40-
(ASK Q.D3 IF Q.S4>1)
D3. Are all of the other people in this household of the same race and ethnicity as you?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(ASK IF D3 = 2, D OR R AND ASK Q.D4 AND Q.D5 IN A SERIES FOR EACH MEMBERIN HH)
D4. Is your (RELATIONSHIP‟s FROM Q.S8[b-j] [INSERT AGE/GENDER FROM Q.S6[b-j]
      AND S7 [b-j]) Mexican, Puerto Rican, Cuban or another Hispanic or Latino group?

      1    No, not of Hispanic origin
      2    Yes, Mexican, Mexican American, Chicano
      3    Yes, Puerto Rican
      4    Yes, Cuban
      5    Yes, other Spanish/Hispanic/Latino
      D     (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(ASK Q.D4 AND Q.D5 IN A SERIES FOR EACH MEMBER IN HH)
D5. Which one or more of the following would you say is (RELATIONSHIP‟s FROM Q.S8[b-j]
      [INSERT AGE/GENDER FROM Q.S6[b-j] AND S7 [b-j])„s race?
     (READ LIST. ENTER ALL THAT APPLY)

      1    White
      2    Black or African American
      3    Asian
      4    Native Hawaiian or other Pacific Islander
      5    American Indian or Alaska Native
      7    Some other race (SPECIFY) ______________
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

ASK D6 – D6a FOR OUTBOUND PHONE SURVEY ONLY
(Universe outbound phone calls only)
D6. Next I have a few questions about the number I dialed to reach you. Is the number (INSERT
      PHONE NUMBER FROM SAMPLE) a cell phone?

      1    Yes, Cell phone
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused




                                              -41-
(ASK Q.D6a IF Q.D6 = 2)
D6a. Is this telephone number?

      1    Listed
      2    Unlisted
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused


(ASK EVERYONE)
INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D7. I would like to ask about any regular, landline telephone numbers in your household, that is, all
     your phone numbers other than cell phone numbers. How many different landline telephone
     numbers does your household have?

      ________ Landline phone numbers (RANGE 0-10)
      DD (DO NOT READ) Don‟t know
      RR (DO NOT READ) Refused

(ASK Q.D7a IF RDD SAMPLE AND Q.D7 = 0)
INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET‟s” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D7a. I‟d like to verify the information you just provided. I believe you indicated that
      (your/TARGET‟s) household has no landline telephone service for incoming and outgoing
      calls. Is this correct?

      1    Yes
      2    No (RE-ASK Q.D7)
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

(ASK Q.D7b IF Q.D7 = 1)
(IF Q.D6 = 2, GEN IN RESPONSE FROM Q.D6a)
D7b. Is this an unlisted telephone number?

      1    Yes
      2    No
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused




                                               -42-
(ASK Q.D7c IF Q.D7 >1)
(IF Q.D6a = 1, GEN IN CODE 1 FOR Q.D7c)
D7c. Are any of these listed numbers?

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused

(ASK Q.D8 IF Q.D7>1)
D8. Excluding any landline numbers used exclusively for fax machines, security systems, the
     internet, or a professional business, how many of these (INSERT RESPONSE FROM Q.D7)
     landline telephone numbers are used for incoming calls?

     ________ Landline phone numbers (RANGE 1-10)
     DD (DO NOT READ) Don‟t know
     RR (DO NOT READ) Refused

(ASK EVERYONE)
(IF Q.D6 =1, GEN IN CODE 1 FOR Q.D9)
INSERT “Do you/your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Does TARGET/their” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D9. Do any members of your household currently have a working cell phone?

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused

(ASK Q.D9a IF Q.D9 = 1)
(IF >HH_COUNT, READ: YOU SAID EARLIER THAT THERE WERE (HH_COUNT) PEOPLE
IN YOUR HOUSEHOLD, HOW MANY HAVE A CELL PHONE?)
D9a. How many people in the household have a cell phone?

     ________ number of people (RANGE 1-10)
     DD (DO NOT READ) Don‟t know
     RR (DO NOT READ) Refused

(ASK EVERYONE)
INSERT “Do you/your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Does TARGET/their” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D10. Is this residence?

     1    Owned by or being bought by you or someone in your household
     2    Rented for cash
     3    Occupied without payment of rent
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                           -43-
INSERT “have you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “has TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D11. How long (have you/has TARGET) lived in Massachusetts? IF NEEDED
     PROBE FOR MONTHS IF LESS THAN 2 YEARS, IF NEEDED: If (you/TARGET) moved
     away for a while, how long (have you/has TARGET) lived in Massachusetts since moving
     back to the state?

     01   ANSWER GIVEN IN YEARS __________ # (2-100) years
     02   ANSWER GIVEN IN MONTHS __________ # (0-24) months
     03   Lived in Massachusetts for entire life
     DD   (DO NOT READ) Don‟t know
     RR   (DO NOT READ) Refused

INSERT “Were you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Was TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D12. (Were you/Was TARGET) born in the United States?

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused

(ASK Q.D13 IF Q.D12 = 2)
INSERT “Are you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “Is TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
D13. (Are you/Is TARGET) a citizen of the United States?

     1    Yes
     2    No
     D    (DO NOT READ) Don‟t know
     R    (DO NOT READ) Refused




                                          -44-
(READ TO EVERYONE)
IN1. My final questions are about income. This information is important because it helps the state
     understand how to make health care more affordable.

(IF TAGE<18 & TMARR=0 & TPAR=0 & RESPONDENT IS PARENT AND
RESPONDENT IS MARRIED, READ :)
(IF HH_COUNT IS GREATER THAN FAM_COUNT INCLUDE VERBIAGE IN
PARENS)
I‟m interested in your family income, that is your income PLUS the income of your
immediate family. (By immediate family I mean your spouse and the children or
stepchildren under 19 who are living with you). For these questions, I‟d like you to think
back to 2007. During 2007, did you) or any of your family members receive any income
from wages or salary?

(IF TAGE <18 & TMARR=0 & TPAR=0 & RESPONDENT IS PARENT AND
RESPONDENT IS NOT MARRIED, READ :)
(IF HH_COUNT IS GREATER THAN FAM_COUNT INCLUDE VERBIAGE IN
PARENS)
I‟m interested in your family income, that is your income PLUS the income of your
immediate family. (By immediate family I mean the children or stepchildren under 19 who
are living with you). For these questions, I‟d like you to think back to 2007. During 2007,
did you or any of your family members receive any income from wages or salary?

(IF TAGE <18 & TMARR=0 & TPAR=0 & RESPONDENT IS NOT PARENT,
READ:)
(IF HH_COUNT IS GREATER THAN FAM_COUNT INCLUDE VERBIAGE IN
PARENS)
I‟m interested in TARGET‟s family income, that is the income from his/her parents PLUS
the income of any immediate family. (By immediate family I mean parents and siblings
under 19 who are living with TARGET). For these questions, I‟d like you to think back to
2007. During 2007, did any of TARGET‟s family members receive any income from
wages or salary?

(IF TMARR=1 & FAM_COUNT>2, READ :)
(IF HH_COUNT IS GREATER THAN FAM_COUNT INCLUDE VERBIAGE IN
PARENS)
INSERT “your/you” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET‟s/his/her/TARGET” IF PERSON ASKING ABOUT IS “TARGET
PERSON”
I‟m interested in [your/ TARGET‟s] family income, that is [your/ TARGET‟s] income
PLUS the income of [your/his/her] immediate family. (By immediate family I mean
[your/(his/her)] spouse and the children or stepchildren under 19 who are living with [you/
TARGET]). For these questions, I‟d like you to think back to 2007. During 2007, did
[you/ TARGET] or any of [your/his/her] family members receive any income from wages or
salary?




                                               -45-
   (IF TMARR=1 & FAM_COUNT = 2, READ :)
   INSERT “your/you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET‟s/his/her/TARGET” IF PERSON ASKING ABOUT IS “TARGET
   PERSON”
   I‟m interested in (your/ TARGET‟s) family income, that is [your/ TARGET‟s] income
   PLUS the income of [your/his/her] spouse. For these questions, I‟d like you to think back
   to 2007. During 2007, did [you/ TARGET] or any of [your/his/her] family members receive any
income from wages or salary?

   (IF TMARR=0 & TPAR=1 & FAM_COUNT>2, READ :)
   INSERT “your/you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET‟s/his/her/TARGET” IF PERSON ASKING ABOUT IS “TARGET
   PERSON”
   I‟m interested in [your/TARGET‟s] family income, that is [your/ TARGET‟s] income
   PLUS the income of the children or stepchildren under 19 who are living with [you/
   TARGET]. For these questions, I‟d like you to think back to 2007. During 2007, did
   [you/ TARGET] or any of [your/(his/her)] family members receive any income from wages
   or salary?

   (IF FAM_COUNT=1, READ :)
   INSERT “you” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   For these questions, I‟d like you to think back to 2007. During 2007, did [you/ TARGET]
   receive any income from wages or salary?

         1   Yes
         2   No
         D   (DO NOT READ) Don‟t know
         R   (DO NOT READ) Refused

   (ASK EVERYONE)
   (DON‟T SCRAMBLE)
   INSERT “you/your” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET/his/her” IF PERSON ASKING ABOUT IS “TARGET PERSON”
   INSERT “family members” IF FAM_COUNT > 1
   IN2. During 2007, did [you/ TARGET] (or any of [your/ his/her] family members) receive
        (INSERT)?

         1   Yes
         2   No
         D   (DO NOT READ) Don‟t know
         R   (DO NOT READ) Refused

   a.   Any dividend income or any interest income from bonds, money market accounts, CDs or other
         investments
   b.   Social Security benefits or any type of cash assistance
   c.   Income from any other sources, such as self-employment, alimony, child support, contributions
         from family or others, unemployment compensation, worker‟s compensation or veteran‟s
         payments, pensions, or anything else
   INSERT “you/your” IF PERSON ASKING ABOUT IS RESPONDENT
   INSERT “TARGET/TARGET”s” IF PERSON ASKING ABOUT IS “TARGET
   PERSON”
   INSERT “immediate family” IF FAM_COUNT > 1

                                                -46-
IN3. Thinking about all the different sources of income [you/ TARGET] (and [your/ TARGET‟s]
     immediate family) received in 2007, what was the combined total income from all sources
     before taxes and other deductions? Was it under (INSERT AMT3 FOR FAMILY SIZE) or
     was it (INSERT AMT3 FOR FAMILY SIZE) or more?
     PROBE: Your best estimate is fine.

      1   Under (INSERT AMT5)
      2   (INSERT AMT5) or more
      D   (DO NOT READ) Don‟t know
      R   (DO NOT READ) Refused

(ASK Q,IN4 IF Q.IN3 = 1)
INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
INSERT “TARGET”s” IF PERSON ASKING ABOUT IS “TARGET PERSON”
INSERT “family” IF FAM_COUNT > 1
IN4. Now, just stop me when I get to the right category. Was [your/ TARGET‟S] total (family)
      income …?
     IF NEEDED: The computer gives me different income values for the question depending on
      the size of your family. (IF NEEDED, PROBE: Your best estimate is fine)
     (READ LIST. ENTER ONE ONLY)

      1   Less than (INSERT AMT1)
      2   (INSERT AMT1) to (INSERT AMT2)
      3   (INSERT AMT2) to under (INSERT AMT3)
      4   (INSERT AMT 3) to under (INSERT AMT4)
      5   (INSERT AMT 4) to under (INSERT AMT5)
      D    (DO NOT READ) Don‟t know
      R    (DO NOT READ) Refused

NOW GO TO Q.IN6




                                            -47-
 (ASK Q.IN5 IF Q.IN3 = 2, D, OR R)
 INSERT “your” IF PERSON ASKING ABOUT IS RESPONDENT
 INSERT “TARGET”s” IF PERSON ASKING ABOUT IS “TARGET PERSON”
 INSERT “family” IF FAM_COUNT > 1
 IN5. Now, just stop me when I get to the right category. Was [your/ TARGET‟S] total (family)
      income …?

       PROBE: Your best estimate is fine.
       (READ LIST. ENTER ONE ONLY)

       1   (INSERT AMT5) to under (INSERT AMT6)
       2   (INSERT AMT6) to under (INSERT AMT7)
       2   (INSERT AMT7) to under (INSERT AMT8)
       3   (INSERT AMT8) or more
       D   (DO NOT READ) Don‟t know
       R   (DO NOT READ) Refused

                        2007 Poverty Guidelines, rounded up to nearest thousand
             100%      150%     200%     250%        300%      400%        500%           600%
FAMSIZE      AMT1      AMT2    AMT3      AMT4       AMT5      AMT6        AMT7           AMT8
1            11000     16000    21000    26000       31000     41000       52000          62000
2            14000     21000    28000    35000       42000     55000       69000          83000
3            18000     26000    35000    43000       52000     69000       86000         104000
4            21000     31000    42000    52000       62000     83000      104000         124000
5            25000     37000    49000    61000       73000     97000      121000         145000
6            28000     42000    56000    70000       83000    111000      139000         166000
7            32000     47000    63000    78000       94000    125000      156000         187000
8            35000     52000    70000    87000      104000    139000      173000         208000
9            39000     58000    77000    96000      115000    153000      191000         229000
10           42000     63000    84000   104000 125000         167000      208000         250000
11           46000     68000    91000   113000 136000         181000      226000         271000
12           49000     73000    97000   122000 146000         194000      243000         291000
13           52000     78000   104000 130000 156000           208000      260000         312000
14           56000     84000   111000 139000 167000           222000      278000         333000
15           59000     89000   118000 148000 177000           236000      295000         354000
16           63000     94000   125000 157000 188000           250000      313000         375000
17           66000     99000   132000 165000 198000           264000      330000         396000




                                              -48-
  (ASK Q.IN6 IF TAGE>17 & EVER UNINSURED IN PRIOR YEAR [Q.H6 = 0+] OR
  IF TAGE <18 & TARGET‟S PARENTS EVER UNINSURED IN PRIOR YEAR [H1ca
  OR Q.H4b = 1 AND Q.I5 NE DD OR RR)
  INSERT “you/your” IF PERSON ASKING ABOUT IS RESPONDENT
  INSERT “TARGET/his/her” IF PERSON ASKING ABOUT IS “TARGET PERSON”
  INSERT “TARGET‟s parent/their IF TAGE<18)
  IN6. Finally, did (you/TARGET/TARGET‟S parents) pay a penalty in (your/his/her//their) taxes in
       2008 for not having insurance coverage by December 31, 2007?

        1    Yes
        2    No
        D    (DO NOT READ) Don‟t know
        R    (DO NOT READ) Refused

  (ASK ZIP IF RDD SAMPLE)
  ZIP What is your zip code?

        ______________ (ENTER ZIP CODE)
        DD (DO NOT READ) Don‟t know
        RR (DO NOT READ) Refused

  (EVERYONE:)
  FINAL: That was my last question. Do you have any questions for me?

   IF NEEDED READ

   For more information on health care coverage in Massachusetts, I can give you two customer service
   numbers:

   For MassHealth, call 1-800-841-2900
   For CommCare or CommChoice through the Connector, call 1-877-623-6765

  IF RDD OR LISTED TELEPHONE FROM USPS SAMPLE READ 1ST VERBIAGE IN
  PARENS
  IF OTHER USPS SAMPLE, READ 2ND VERBIAGE IN PARENS
  The last thing I need is your name and mailing address to (enter you in the drawing
  for the $100 prize gift certificate or Red Sox tickets as our thank you for your contribution to this
  important research/send you your $20 thank you for your contribution to this important research and
  enter you in the DRAWING for the $100 gift certificate or 2 Red Sox tickets.)

Name: _____________________________
Street: _____________________________
City: _______________________________
Zip code: ___________________________




                                                 -49-

				
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